If Your Doctor Told the Truth at 3am...

"In the end, when Mr Foster started coughing up blood the on-call surgeon was stuck in traffic, the nursing staff was busy losing the lottery, his original doctor was thanking a garbage man, and the covering physician was incapacitated. And what was Mr Forster doing? He was dying in the hands of the Interns! Does that about sum it up?" ~ Kelso, Scrubs

First off, uber mega congrats to the final meds who are done with their exams! I know the results aren't out until Friday, but have an awesome week! Unwind! Be nice to yourselves! You all deserve it!

I've been keeping a bit of a countdown going (as some of you know) until this intern year ends... It's my own form of therapy. It's to keep my eye on the prize. But I think I'm just now realising that as soon as that timer ends, all those final meds just slip into the vacant intern posts. I'm not sure I even remember how that was. There's a small part of me that knows I've learned a helluva lot since I started, but that part of me still tends to be drown out by the sheer volume of the gaps in my knowledge.

I have often wished that I cared a little less, expected less of myself, had lower standards, could just "turn off" the worry and concern. I can't. And that's one of the reasons I have been chaffing under the yolk of the job I'm in. I know how dangerous things can get on call. I know how close to disaster I've been. I know how thin the cover is. And I know it's only a matter of time before I run out of fingers to keep plugging the holes. So... as a bit more therapy for myself, I'm going to try to be funny (and bitingly real) about a night on call, and how that sometimes goes... For those of you that don't work in medicine, keep in mind, sometimes, you work a full day shift before this. Sometimes, you have to work the next day... Sometimes, it's just the "12 hour" overnight shift.

7:55pm:
* Drop bag in res
* Get arrest bleep from intern going off-call
* Ask if there's anything important I should know about...

8pm:
* Paged to chart warfarin - don't know the patient, don't know why they're on warfarin, don't know what their INR is today... they had 4mg yesterday... so... yeah, let's go with that.
* Paged to chart IVF - normal, healthy, young patient, fasting from midnight for a scope tomorrow... fair enough. Just some saline... What do you mean they don't have a cannula? Fine. Insert green line.
* Paged to r/v CXR for NG siting - Can't even see the tip of the NG because the x-ray is off centre. But sure, it's clearly below the diaphragm, so that's fine. Pull the wire, start the feeds.
* Paged to r/v desaturation - Patient ++BMI (like maybe 39), known COPD, known OSA, on home O2... For some reason doesn't have oxygen mask on now... Put on mask, sir. Sats back to 94%. No, that's normal for him. No I'm not doing an ABG, you took off his O2, that's why it was low. What do you mean he needs a cannula? You paged the team ALL day? Who did you page? Yeah, that intern was post-call, they weren't here. Did you page the SHO at all? No? Seriously? ... Insert gray line, just because I can, and because anything shorter wouldn't make it through the fat.
* Paged for warfarin x3 - yeah... ok... done, done and... Wait no... Why is this one on hold? Is it still on hold? The patient is actively bleeding from an ulcer?! No, I'm not charting that tonight... No, I'm sure. No, I won't ring the reg! If they're bleeding, we're not giving warfarin.

9pm:
* Paged to re-chart paracetamol - ran outta room in the PRN section, fine, rewrite and leave.
* Paged to r/v patient with chest pain - patient has pain... in the ribs... pleuritic... and oh... in the hospital for rib fractures. Why aren't you giving her the oxynorm? ... Because of the pain?... Oxynorm is FOR the pain (PALM-FOREHEAD)... No, I'm not doing an ECG. No I'm not doing a TNI. Give her the pain meds! That's what they're for!
* Paged to r/v patient with low BP - BP 105/60, patient sleeping... uh, let her sleep.
* Paged to r/v patient post-fall - patient is confused normally, shockingly confused now. No obvious head trauma, seems to have slipped onto the floor and landed on their bum. No bruises. Oriented in person... and that's about it... well... keep an eye on her. What do I mean? I mean neuro obs... About every 2 hours... Yes all fucking night. No, I will not order a CT Brain right now.
* Paged for IVC - Patient on 3 abx for VRE... yeah, I'll put one in. Patient has zero veins. So... you're telling me that the intern on the team, the SHO on the team, and the reg on the team couldn't get this cannula in and you expect me to get it now? Why didn't they get anesthetics? Fine... I'll try. (15 minutes later) Yes... there is now a cannula in their GSV, right leg. What do you mean you wanted it in their arm? No, I don't care. They have one in now, deal with it.
* Paged to chart night sedation - Patient 3/7 post respiratory arrest, normal sats at 92%, COPD... brittle... hm... No. No night sedation.

10pm:
* Paged for tachycardia - Patient "tachy" at 90. Usual HR is 85, BP was up, now low, mild pyrexia ... just vomited? Oh... Do they have an antiemetic charted? Ok, well why don't you give them that. No, the tachy is probably from the vomiting.
* Paged to r/v low urine output - post-op, no urine in the bottle... Ok, BP normal, IVF show roughly 1L in... Sir, have you peed? Oh, you walked to the toilet and peed? Ok... awesome.
* Paged to r/v need for IVF - IVF charted in kardex by team... What do you want from me? If the team charted it, give it. You seriously expect me to take what the team wrote down at 5pm and change it? No.
* Paged to remove abdominal drain - uh... ok? I've never seen one of these before. I've not only never seen one before, I haven't seen one being put in or taken out. Ring reg. How do these work? "You just take it out." Ah, ok, thanks for clarifying... I'll take care of that now. Look at drain closely. Pull on sterile gloves, pull off adhesives, study base of drain for sutures, cut those off, study drain again... Pull out... Dodge the shot of ascitic fluid that shoots out too... ew. Apply pressure. Apply more pressure.... Pager goes off, pager goes off, keep applying pressure. Pager goes off, what the hell, that's this ward! Apply dressing. Throw away all the dirty bits. Wash hands.
* Return pages - run around like a scut monkey for an hour...

11pm:
* Paged to r/v patient that is deteriorating - deteriorating how? They're NFR... ok... But how are they deteriorating? They're dying... right... I'd assume if they're palliative. But what exactly is wrong? They're chesty and it's upsetting the relatives... Ah... That I can do something about. Review chart to make sure I know the allowed intervention for patient. Chart comfort measures. Discuss with night staff. Pop head into room and have brief but compassionate conversation with family. We will keep him as comfortable as possible. Leave note in chart.
* ... Regretting the crap I ate for dinner...
* Paged to r/v patient that is "off" - Patient is definitely off... in fact, kinda turning blue, diaphoretic, complaining of pain... Shit shit shit. Throw on oxygen, sit him upright, demand to know why he's in hospital. Give neb, ABG, fbc, ue, coag + ddimers (I hate ddimers), two IVCs, ecg, and cxr... Ring the reg... Spew rough background and the results I now have... I think it's a PE... Well, should I start therapeutic innohep? ... Any suggestions? ... Right, ok. I'll do what think is best and since YOU would have to get the radiologist in, I'm just gonna order the CTPA for tomorrow then, yeah? Thanks.

12am:
* Now to catch up on the 14 pages that came in while dealing with that other gentleman...
* Rewrite kardex - meh, rewrite 2 items into new kardex and label it II of II. They should have done that themselves today
* IVC for 2am ABX - yeah, I'm getting the tired blurry vision, throw in a pink line because I can't deal with a green right now.
* Run a BNP from CCU - fetch the HF clinic key from the A&E office, plate the sample, start it running, leave the office unlocked, return the key, return to the office, wait another 10 minutes, take the print out back to CCU... this in no way changes the management... 
* First dose ABX x2 - patients sent up to ward from A&E without first dose given... nice...
* Patient with SBG of 24 - give stat dose of actrapid... as per the sliding scale... thanks for letting me know...

1am:
* Paged for IVC - Wait, that's my patient. He's not on IV anything. Go to ward, flip through kardex, yeah, that paracetamol is iv OR po... give it orally!
* ... Really should have peed earlier...
* Paged to admit patient - Uh... it's 1am, what the hell? No you haven't paged me about this! What do you mean they came up from A&E without an admission or kardex?! I'll tell you what, have another look, because if I get there and the patient has been admitted and has a kardex, I am not answering another page from you again. Swing through the A&E on the way to the ward, grab the "non-existant" kardex from the trolley, go up to the ward... Here's the kardex, there's the admission note. Thanks for calling.
* Paged to r/v irregular heart beat - well, they're in afib. It's slow. It's been previously diagnosed. They're on all the proper meds for it. No I don't want to do an ecg or TNI. No I'm not giving meds. Do you even know what afib means?!

2am:
* Paged to chart night sedation - uh... that patient is asleep.
* Paged to r/v agitation - Patient in alcohol withdrawal... Can you draw up a dose of ativan? I'll be there in a minute to give it. Oh you can't? Why the hell not? Ok... fine, I'll be there shortly. Get to ward, drug press locked. Would you open this? You don't have keys? Where are the keys? Right... sit at table and twiddle thumbs for 5 minutes. Ok, press open, draw up the ativan, No, I don't need you to check it, where the fuck is the patient? Meet patient, have a quick chat, patient lying in bed seemingly calm. So... Why did you think he was agit- FUCK! (narrowly avoid getting punched in face) Patient starts thrashing and spitting... Riiight... Ok, 3 nurses help hold him down and I give a stat dose of ativan in his left arse cheek. Chart it in the kardex, chart PRN options, chart librium, write note in chart suggesting pabrinex tomorrow.
* Paged to r/v abnormal potassium - K+ = 3.4 (normal for lab 3.5)... resist urge to strangle someone... "But, doctor, don't you want to fix it?" Yeah, give the guy a banana for breakfast... walk back to res.
* Hi bed... take of sneakers, take off steth, pull pen out of hair, sit on bed, pager goes off... damn.

3am:
* Paged to pronounce - Palliative patient has passed away. Get out of bed, put on crocs, go to ward and priest is in room with family. Will come back in a few minutes.
* Paged to CCU - chart Mg for patient with tachy runs, chart pain meds for NSTEMI that has no analgesia charted, give first dose taz to intubated patient with temp spikes.
* Return to ward, pronounce patient, write note in chart, sign mortuary tf form, explain the next few hours to the family. Don't know the answer to most of their questions as patient isn't actually mine, tell them to discuss with the nursing staff, and offer my condolences.
* "Doctor, since you're up..." - yawn, rub eyes, probably should have washed my hands. Wash hands, wipe down steth, sign for bloods tomorrow, chart stat dose actrapid from before, sign off on 2x MSU and 6x swabs, rewrite one page of kardex, insert IVC for patient fasting and on IVF (went with a blue line because I was lazy), change another patient from IV lasix to PO (mostly because it has the same bioavailability, but also because I don't want to put in another cannula).
* Paged to r/v increased drowsiness - ... Wait a sec... This is the patient I just sedated... They're supposed to be drowsy! Unless you'd prefer he be bitey and punchy?! I'll come by and reverse his sedation. No? Awesome. Bye.
* Paged to chart glycerin suppositories - No bowel motion for 2/7, not eating, poor PO intake, team did not start laxatives during the day... Uh... No? Then no.
* Walk back to res... hello again bed.

4am:
* Paged to r/v abnormal LFTs - JESUS! his AST/ALT are >1000... Oh wait, he's in for hepatorenal failure. And you're telling me that the team is aware of these? And they're actually getting better? What the fuck is wrong with you? It's 4am!
* Paged b/c patient on telemetry was bradycardic for 10 seconds - well... how brady? 46? uh... what's his regular? 60? And he's sleeping, is he? Uh... ok...? What do you want me to do? You just have to tell me? Great. You've told me.
* Paged to rewrite kardex - Uh... no. The team can do that in the morning. PS: It's 4am, what the hell.
* Paged to chart glycerin suppositories - Patient is in "agony."... pager goes off again...
* Paged for transfer letter - patient for coronary angiogram tomorrow. What time? 1pm? Fuck off.
* Ring back ward re: glycerin suppositories - speak to different nurse. No, patient is asleep. Was already given the suppositories, they just need to be charted... Oh they do? Well, I didn't authorise their use, so I'm not charting them.
... Quarter to 5... Try to go back to sleep.

6am:
* Paged to chart glycerin suppositories - Please, doctor, before the day staff comes on. No. *click*
* Paged for early morning ABG due as per the request of the consultant. Uh, define early morning? "Don't know. I guess before nine?" Right... I'll be up before 9.
* Paged for repeat TNI in A&E for an admitted patient - *sigh* go down to A&E. Where are the TNI forms? You don't have any? Ok... spend 30 minutes finding a new TNI form. Fill it out. Find the patient. Hi sir, I'm just going to take a wee blood sample if that's ok. "NO! It's not ok! Fuck off!" *sigh* return to nurses station. That patient is very agitated and is refusing bloods. "Yes, we tried and he said no, that's why we paged you." Ugh... Well he's refusing me too, so the team can do it in a few hours.
* Paged by A&E... wait, I'm effing in the A&E! What?! "We think this patient was supposed to be on ABX, but they were never charted." ... (blink, blink) I don't understand. "Well, the consultant said they might need ABX, but like... they aren't in the kardex." ... (blink, blink)... Uh... What exactly do you want me to do about that? ... "Well, can you check?" ... (blink, blink) ... Uh... Check what? Check the chart? Because, I would hope that you can read too... "No, check with the consultant." ... (blink, blink)... (blink, blink)... What? Wait, you're serious? It's 6am. The consultant will be in soon. I am not ringing him on his mobile to ask that!
* Paged to r/v urinary retention - "Patient hasn't peed in like 4 hours." ... I'm guessing they're sleeping? Four Hours?! Oh my God! I haven't peed in 10 hours! Fuck! Tell you what, I'll come put a catheter in him if you put a catheter in me... hello? I think they hung up on me.

7am:
* Go to ward and do the "early morning" ABG. Manage to hit the artery on second try. Take sample to CCU... machine broken. Uh, fine, go to resus in A&E... machine broken. *Sigh* Go down to the lab... swipe in... machine broken. Wtf... shit... There's another machine somewhere... where was it... Oh yeah, in the SCBU... Run the sample. Return the print out to the chart. Get asked to put in 2 more IVCs on that ward... I consider it... One of them is my patients. Put in that IVC. The other one... I just put that in last night. Oh they pulled it out? Forget it.
* Paged to chart IVF - No. Leave that for the team.
* Paged to admit a patient to dayward - It's like... 7:55. No. By the time I hang up this phone, it'll be 8. There's a different intern on call. And the team can be called.

8am:
* Page incoming intern - no response.
* Consider turning off my bleep, but generally leave it on until I hand of the arrest bleep so people can find me if they don't have their mobiles.

8:15am:
* Ring fellow intern - where are you? You're supposed to be carrying the arrest bleep... I'm tired.
* Paged by team back in hospital - "Why did you give those suppositories?" Actually, I didn't. Because I didn't think the patient needed them, I didn't authorise them. I didn't ask them to be given. Talk to the nurses.
* Paged to r/v patient for CXR - "Doctor, patient is for repeat CXR today. Will you come order?" Uh... who's patient is it? PS: NO! The X-ray dept won't be open until half-eight. I'm not on call anymore. The team can do it when they're here in 45 minutes. Calm down.
* Ring other intern - Just a heads up, one of your patients passed away last night. Their family is still here. Let your boss know?
* Paged to rewrite kardex - would you please fuck off.

8:30am:
* Ring fellow intern - seriously dude... it's been a long night. I have an hour long drive in front of me and about half a day of errands to do before I can sleep... Where the fuck are you?

8:32am:
* CARDIAC ARREST BLEEP - CARDIAC ARREST A&E! CARDIAC ARREST A&E! - fml... Run to A&E. Reg looks at me funny, why are you still here? Well... someone has to carry this thing. Nurse looks at me, "Are you the anesthetist?" (insert crazy laugh) HAHA... No... ED SHO rocks in, looks at me, "Hey, are you the reg?" (look at reg with super confused look on my face) Uh... no... He is. (look around... something like 13 people in the room now), Hey reg, can I go... Too many cooks and all? I get the nod, I leave.

8:33am:
* Drink bad instant coffee in the canteen.
* Look up and see fellow intern walk past with his team... wtf... Hey assclown, please accept this arrest bleep and slap upside the head as my parting gift. Hand over the arrest bleep and officially go off-call.
* Finish drinking bad coffee.

8:40am:
* Collect bag from res and head toward exit

8:42am:
* Run into team... Hand over anything and everything from last night that had to do with our patients. Remind them of 5 super important jobs that need to be done today. No... I'm not here today... I'm going to go sleep... Uh... No, they're not paying us post-call, so I'm going home. In fact, I just attended an arrest that I won't be paid for. I'll see you tomorrow.

9am:
* Dump bag into boot of car, climb into the driver's seat, start car, stare blankly at the low petrol light... damn. Swipe card won't open the gate... honk... Wait for security to let me out. Bye hospital...

9:15am:
* Fill car with petrol. Purchase another bad cup of coffee.
* Sit in rushhour traffic for next hour and a half...

10:35am:
* Park outside my flat
* Stumble down stairs and into room
* Strip... these dirty scrubs aren't touching anything in my room.
* Put on clean shirt
* Pass out, face down in my bed.

2pm:
* Wake up... wonder how many of the patients I saw last night are well... wonder if I made a mistake... worry that I missed something important... What if that guy was actually in urinary retention? What if me ringing the consultant and starting antibiotics would have made a difference for the patient? What if those LFTs had been really off, and I should have seen them, I should have reviewed that patient... What if I'd been wrong about that ABG and it wasn't improved? What if it was getting worse? Or if that guy that needed the TNI was actually having a NSTEMI and I didn't take the bloods because he'd refused? Well, taking them when he'd refused would be assault, but like, it might have saved his life?...
* Get up, shower, put on civies, run errands, try to be a normal person for a few hours...

"It's never easy when someone accuses you of screwing up, especially when you know it's true. When that happens you can't shrug it off, because in a hospital the best way to learn from your mistakes is to carry them with you." ~ JD, Scrubs

So... to my fellow interns, let's be sure we're learning from our mistakes. To the incoming interns, be ready to make a few... and learn from the experience.